Gastroenterology Today Spring 2020

Volume 30 No. 1 

Spring 2020 

Gastroenterology Today 

Passionate about Endoscopy? 

We are clearing NHS trust waiting lists 

one weekend at a time, and 

we need your help 

In this issue 

18 Week Support Gastroenterology: 

Building Expert Teams 

The Gutless Journey 

Risk of Hepatic Decompensation 

and Mortality 

An update on Colonic 

Diverticulosis

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CONTENTS 

CONTENTS 

5 EDITORS COMMENT 

6 FEATURE The Gutless Journey 

8 FEATURE Bowel Cancer Awareness Month – detect the 

Matthew’s Perspective: 

undetected with Artificial Intelligence 

10 FEATURE Risks of hepatic decompensation and mortality 

in patients with cirrhosis requiring surgery 

14 FEATURE An Update on Colonic Diverticulosis 

16 NEWS 

22 BSG POSTERS 

Gastroenterology Today 

What approach has 18 Week Support 

taken with regards to building an 

expert insourcing team? 

This issue edited by: 

Andy Poullis 

c/o Media Publishing Company 

Media House 

48 High Street 

SWANLEY, Kent BR8 8BQ 

Dr Matthew Banks is the Clinical Director for 18 Week Support Gastroenterology. ADVERTISING He believes it starts & with CIRCULATION: 

recruiting the 

best clinicians. ‘At 18 Week Support we set the bar very high. We only recruit Media clinicians Publishing whose JAG performance Company data is well 

above the national standards. In addition, we monitor each clinician’s KPIs while they work with 18 WS. While the JAG data 

Media House, 48 High Street 

is an excellent quality indicator, we now want to go a step beyond that and monitor the Non-Technical skills (NTS) of each 

clinician as well. We now know that NTS plays an important role in safe and SWANLEY, effective team performance. Kent, BR8 Therefore, 8BQ in our 

quest to develop excellent teams who deliver a world-class service, we must Tel: focus 01322 on NTS’. 660434 Fax: 01322 666539 

E: info@mediapublishingcompany.com 

Tammy and Lisa’s Perspective: 

www.MediaPublishingCompany.com 

Tammy Kingstree is Lead Nurse for Endoscopy. 

‘It is extremely important that there are good working relationships within the team. This starts with strong leadership from 

our senior nurse coordinators who are trained to manage the patient pathway, PUBLISHING manage a team of DATES: 

staff they may not know 

and to deal effectively with any issues which may arise on the day’. 

February, June and October. 

Lisa Phillips is Lead Nurse for Endoscopy. 

‘The team objectives are clear. Excellent patient experience and good patient COPYRIGHT: 

outcomes. Because the objectives are clear, 

team cohesion and focus are exceptionally good. It therefore shouldn’t matter Media that we Publishing are in an unfamiliar Company endoscopy unit, 

the service should be seamless. If it isn’t, we do not stop until we get it right. 

Media House 

If you have an excellent NHS record and want to help clear NHS waiting list 48 backlogs, High reduce Street RTT waiting times and 

provide high-quality patient care, get in touch by calling on 020 3869 8790 SWANLEY, or email recruitment@18weeksupport.com 

Kent, BR8 8BQ 

COVER STORY 

What approach has 18 Week Support taken with 

regards to building an expert insourcing team? 

Matthew’s Perspective: 

Dr Matthew Banks is the Clinical Director for 18 Week Support Gastroenterology. 

He believes it starts with recruiting the best clinicians. ‘At 18 Week Support we set the 

bar very high. We only recruit clinicians whose JAG performance data is well above the 

national standards. In addition, we monitor each clinician’s KPIs while they work with 

18 WS. While the JAG data is an excellent quality indicator, we now want to go a step 

beyond that and monitor the Non-Technical skills (NTS) of each clinician as well. 

We now know that NTS plays an important role in safe and effective team performance. 

Therefore, in our quest to develop excellent teams who deliver a world-class service, 

we must focus on NTS’. 

Tammy and Lisa’s Perspective: 

Tammy Kingstree is Lead Nurse for Endoscopy. 

‘It is extremely important that there are good working relationships within the team. 

This starts with strong leadership from our senior nurse coordinators who are trained 

to manage the patient pathway, manage a team of staff they may not know and to deal 

effectively with any issues which may arise on the day’. 

Lisa Phillips is Lead Nurse for Endoscopy. 

‘The team objectives are clear. Excellent patient experience and good patient outcomes. 

Because the objectives are clear, team cohesion and focus are exceptionally good. 

It therefore shouldn’t matter that we are in an unfamiliar endoscopy unit, the service 

should be seamless. If it isn’t, we do not stop until we get it right’. 

If you have an excellent NHS record and want to help clear NHS waiting list backlogs, 

reduce RTT waiting times and provide high-quality patient care, get in touch by calling 

on 020 3869 8790 or email recruitment@18weeksupport.com 

PUBLISHERS STATEMENT: 

The views and opinions expressed in 

this issue are not necessarily those of 

the Publisher, the Editors or Media 

Publishing Company. 

Next Issue Summer 2020 

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M00242EN

EDITORS COMMENT 

EDITORS COMMENT 

“Over 1000 

miles to walk 

with a need 

to arrange 

transportation 

and 

administration 

of TPN 

throughout 

is a first for 

this historic 

route.” 

Gutless walk 

For many of us the thought of a walk the length of Great Britain would be daunting, adding 

in the complexity of taking this on with short bowel syndrome and TPN dependence takes 

this challenge to a new level. Over 1000 miles to walk with a need to arrange transportation 

and administration of TPN throughout is a first for this historic route. 

There are many records and exceptional stories on how this journey has been completed 

(walking and cycling are the obvious, hitchhiking and golfing some of the more unusual) 

but the challenge and logistics of the plan Justin Hansen writes about in this edition of 

Gastroenterology Today is without comparison. 

This challenge follows on from his gutless kayaking trip that we have previously reported 

on. 

These challenges are inspirational for all of us. 

There are links in the article if anyone is able to offer support along the way to Justin and 

Alice. 

A Poullis 

St George’s Hospital 


5

FEATURE 

THE GUTLESS JOURNEY 

Until October 2001, aged 41, Justin had been very fit and healthy. 

He then started to develop a series of seemingly unrelated ailments. 

Strange rashes appeared, his joints seized up and his nail beds 

became infected. At one point he had over 100 mouth ulcers. 

They estimate that this 1300 mile walk will take between 3 and 4 

months to complete. They shall be raising funds for Penny Brohn, the 

cancer support charity, and for the PINNT (Patients On Intravenous & 

Nasogastric Nutrition Therapy) support group. 


6 

By March 2003 Justin was very ill and losing weight. His sister took him to 

the local accident and emergency department where Justin was admitted 

to hospital. After a few days of investigations it became clear that his large 

intestine (colon) needed to be removed. 

This tissue was sent to the pathology 

laboratory, where it was diagnosed that 

Justin had Crohn’s disease. 

About a week after the surgery, 

Justin’s recovery ran into problems. 

As the complications mounted, Justin 

was moved into intensive care, then 

transferred to St. Mark’s Hospital 

for more specialist care. That first 

hospital visit lasted 8 months. Most 

of the following four and a half years 

were spent in hospital recovering from 

further surgery to correct abscesses, 

adhesions, collections, infections and 

fistulas. When not in hospital Justin was 

being looked after by his family and 

awaiting further surgery. 

By 2006, and after a lot more surgery, 

Justin had lost most of his small bowel 

too (short bowel syndrome) and needed total parenteral nutrition (TPN) 

administration 12 hours a day. Justin has been taught to self-manage 

this treatment. The liquid nutrition is stored at between 2 and 8 degrees 

in a dedicated fridge. 

Since his last abdominal surgery in August 2007 Justin has completed a 

BSc Psychology at the University of Portsmouth. In March 2009, however, 

Justin had a heart infection which led to a stroke and the need for open 

heart surgery. Because of this he needed to take a year off from university. 

Having completed his psychology degree in June 2011, Justin switched 

to the University of Brighton to take an MSc in Occupational Therapy. 

He then did this: http://www.gutlesskayaking.com/ 

The next steps 

Alice and Justin will start walking from Lands End to John O Groats on 

April 28th 2020. The date is significant: it is the four year anniversary 

of Alice’s bilateral breast cancer diagnosis. Justin has short bowel 

syndrome and needs intravenous nutrition to survive. Justin will receive 

TPN throughout the walk and his medical supplies will be kept in a 

fridge in their campervan. 

Alice and Justin need support 

“Here’s how we’re planning to do the walk: 

1. Drive our campervan to a suitable 

campsite that is close as possible 

to the end of the next day’s walk. 

Sleep. 

2. In the morning, take transport (bus, 

taxi, train, friends etc) to the start of 

the day’s walk. VOLUNTEERS – can 

you help us with transport or let us 

park up in your drive and plug in? 

3. Walk to the van. Sleep. 

4. Next morning, get up and walk all 

day. 

5. Take transport (bus, taxi, train, 

friends etc) back to the van. 

6. Go back to 1) 

This is the link to our Google Map 

of the route: https://goo.gl/maps/ 

H5z79hSPqfNmuNwg6 

This is what we need help with: 

A. Transport to and/or from our campervan. This will usually be a 

distance of about 15 miles. This is going to be especially helpful in 

Scotland where there are less options for public transport. 

B. Do you have a driveway that we can park on overnight? We would 

need to be able to plug the van in to a regular domestic socket, and 

we would need access to a toilet. We are self funding this trip so your 

support with this will help keep our costs down. 

C. If you know anyone near our route who may be able to help then 

please forward our details to them, thank you. 

Please email us at Gutlessend2end@gmail.com if you’d like to help us 

with this challenge. Meanwhile, have a look at our social media: 

uk.virginmoneygiving.com/Team/GutlessEnd2End 

www.facebook.com/gutlessend2end/ 

twitter.com/gutlessend2end 

www.instagram.com/gutlessend2end 

www.youtube.com/channel/UCXJhVAgoktdqCNQRGu63lCg 

Thank you for reading this far and for your support” 

Justin Hansen & Alice McGarvie

Life feels good when they’re under control FEATURE 

1–8 

CROHN’S DISEASE 

Indicated for the induction of 

remission in patients with mild to 

moderate active Crohn’s disease 

affecting the ileum and/or the 

ascending colon 9 

ULCERATIVE COLITIS 

Indicated for ulcerative 

colitis involving rectal and 

recto-sigmoid disease 10 

MICROSCOPIC 

COLITIS 

Indicated for the induction 

and maintenance of remission 

in patients with microscopic 

colitis 9 

Supporting research 

and development in 

microscopic colitis 

ENTOCORT CR 3mg Capsules (budesonide) - Prescribing 

Information 

Please consult the Summary of Product Characteristics (SmPC) for full 

prescribing Information 

Presentation: Hard gelatin capsules for oral administration with an opaque, 

light grey body and an opaque, pink cap marked CIR 3mg in black radial print. 

Contains 3mg budesonide. Indications: Induction of remission in patients with 

mild to moderate Crohn’s disease affecting the ileum and/or the ascending 

colon. Induction of remission in patients with active microscopic colitis. 

Maintenance of remission in patients with microscopic colitis. Dosage and 

administration: Active Crohn’s disease (Adults): 9mg once daily in the 

morning for up to eight weeks. Full effect achieved in 2-4 weeks. When 

treatment is to be discontinued, dose should normally be reduced in final 2-4 

weeks. Active microscopic colitis (Adults): 9mg once daily in the morning. 

Maintenance of microscopic colitis (Adults): 6mg once daily in the morning, or 

the lowest effective dose. Paediatric population: Not recommended. Older 

people: No special dose adjustment recommended. Swallow whole with water. 

Do not chew. Contraindications: Hypersensitivity to the active substance or 

any of the excipients. Warnings and Precautions: Side effects typical of 

corticosteroids may occur. Visual disturbances may occur. If a patient presents 

with symptoms such as blurred vision or other visual disturbances they should 

be considered for referral to an ophthalmologist for evaluation of the possible 

causes. Systemic effects may include glaucoma and when prescribed at high 

doses for prolonged periods, Cushing’s syndrome, adrenal suppression, 

growth retardation, decreased bone mineral density and cataract. Caution in 

patients with infection, hypertension, diabetes mellitus, osteoporosis, peptic 

ulcer, glaucoma or cataracts or with a family history of diabetes or glaucoma. 

Particular care in patients with existing or previous history of severe affective 

disorders in them or their first degree relatives. Caution when transferring from 

glucocorticoid of high systemic effect to Entocort CR. Chicken pox and measles 

may have a more serious course in patients on oral steroids. They may also 

suppress the HPA axis and reduce the stress response. Reduced liver function 

may increase systemic exposure. When treatment is discontinued, reduce 

dose over last 2-4 weeks. Concomitant use of CYP3A inhibitors, such as 

ketoconazole and cobicistat-containing products, is expected to increase the 

risk of systemic side effects and should be avoided unless the benefits 

outweigh the risks. Excessive grapefruit juice may increase systemic exposure 

and should be avoided. Patients with fructose intolerance, glucose-galactose 

malabsorption or sucrose-isomaltase insufficiency should not take Entocort CR. 

Monitor height of children who use prolonged glucocorticoid therapy for risk of 

growth suppression. Interactions: Concomitant colestyramine may reduce 

Entocort CR uptake. Concomitant oestrogen and contraceptive steroids may 

increase effects. CYP3A4 inhibitors may increase systemic exposure. CYP3A4 

inducers may reduce systemic exposure. May cause low values in ACTH 

stimulation test. Fertility, pregnancy and lactation: Only to be used during 

pregnancy when the potential benefits to the mother outweigh the risks for the 

foetus. May be used during breast feeding. Adverse reactions: Common: 

Cushingoid features, hypokalaemia, behavioural changes such as nervousness, 

insomnia, mood swings and depression, palpitations, dyspepsia, skin reactions 

(urticaria, exanthema), muscle cramps, menstrual disorders. Uncommon: 

anxiety, tremor, psychomotor hyperactivity. Rare: aggression, glaucoma, 

cataract, blurred vision, ecchymosis. Very rare: Anaphylactic reaction, growth 

retardation. Prescribers should consult the summary of product characteristics 

in relation to other adverse reactions. Marketing Authorisation Numbers, 

Package Quantities and basic NHS price: PL 36633/0006. Packs of 50 

capsules: £37.53. Packs of 100 capsules: £75.05. Legal category: POM. 

Marketing Authorisation Holder: Tillotts Pharma UK Ltd, The Stables, 

Wellingore Hall, Wellingore, Lincoln, LN5 0HX. Date of preparation of PI: 

February 2020 

ENTOCORT (budesonide) ENEMA - Prescribing Information 

Please consult the Summary of Product Characteristics (SmPC) for full 

prescribing Information 

Presentation: 0.02 mg/ml budesonide (2 mg budesonide/100 ml) solution 

for rectal suspension. Each Entocort Enema consists of 2 components: a 2.3 

mg faintly yellow, circular biconvex tablet with the engraving BA1 on one side 

and 2.3 on the other side; a 115 ml clear colourless solution. Indications: 

Ulcerative colitis involving rectal and recto-sigmoid disease. Dosage and 

administration: Route of administration: rectal. Adults: One Entocort 

Enema nightly for 4 weeks. Full effect is usually achieved within 2–4 weeks. 

If the patient is not in remission after 4 weeks, treatment may be prolonged 

to 8 weeks. Paediatric population: Not recommended. Older people: Dosage 

as for adults. No dosage reduction in patients with reduced liver function. 

Instruct the patient to read the instructions for use. Reconstitute the enema 

immediately before use. Ensure the tablet is completely dissolved. Administer 

in the evening before bed. Contraindications: Hypersensitivity to the active 

substance or the excipients. Warnings and Precautions: Side effects typical 

of corticosteroids may occur, including glaucoma. Visual disturbances may 

occur. If a patient presents with symptoms such as blurred vision or other visual 

disturbances they should be considered for referral to an ophthalmologist for 

evaluation. When patients are transferred from steroids of higher systemic effect 

they may have adrenocortical suppression; monitoring may be considered 

and the dose of systemic steroid should be reduced cautiously. Replacement 

of high systemic effect steroid treatment with Entocort enema sometimes 

unmasks allergies which were previously controlled by the systemic drug. 

Reduced liver function affects the elimination of glucocorticosteroids, causing 

lower elimination rate and higher systemic exposure, with possible systemic 

side effects. Care when considering systemic corticosteroids in patients with 

existing or previous history of severe affective disorders in themselves or first 

degree relatives e.g. depressive or manic-depressive illness and previous 

steroid psychosis. Systemic effects of steroids may occur, particularly at high 

doses and for prolonged periods, including Cushing’s syndrome, adrenal 

suppression, growth retardation, decreased bone mineral density, cataract, 

glaucoma and very rarely a wide range of psychiatric/behavioural effects. 

Contains lactose and methyl-, propyl-parahydroxybenzoate. Caution in patients 

with hypersensitivity to these. Some patients may feel unwell in a non-specific 

way during withdrawal. When Entocort Enema is used chronically in excessive 

doses, systemic glucocorticosteroid effects may appear. However, the 

dosage form and the route of administration make any prolonged overdosage 

unlikely. Interactions: Raised plasma concentrations and enhanced effects of 

corticosteroids have been reported in women also treated with oestrogens and 

contraceptive steroids. Inhibitors of CYP3A4 can increase systemic exposure 

to budesonide several times and the combination should be avoided. If this 

is not possible, the period between treatments should as long as possible, 

and a reduction of the budesonide dose could also be considered. Other 

potent inhibitors of CYP3A4 are also likely to markedly increase plasma 

levels of budesonide. Concomitant treatment with CYP3A4 inducers may 

reduce budesonide exposure and require a dose increase. Because adrenal 

function may be suppressed, an ACTH stimulation test for diagnosing pituitary 

insufficiency might show low values. Fertility, pregnancy and lactation: 

Only to be used during pregnancy when the potential benefits to the mother 

outweigh the risks for the foetus. May be used during breast feeding. Adverse 

reactions: Common: depression, gastrointestinal disturbances (flatulence, 

nausea, diarrhoea), skin reactions (urticaria, exanthema). Uncommon: agitation, 

insomnia, anxiety, psychomotor hyperactivity, duodenal or gastric ulcer. 

Rare: signs or symptoms of systemic glucocorticosteroid effects, aggression, 

glaucoma, cataract including subcapsular cataract, blurred vision, pancreatitis, 

ecchymosis, osteonecrosis. Very rare: anaphylactic reaction. Prescribers should 

consult the summary of product characteristics in relation to other adverse 

reactions. Marketing Authorisation Numbers, Package Quantities 

and basic NHS price: PL 36633/0007. Packs of 7 enemas: £33.66. Legal 

category: POM. Marketing Authorisation Holder: Tillotts Pharma UK Ltd, 

The Stables, Wellingore Hall, Wellingore, Lincoln, LN5 0HX. Date of preparation 

of PI: March 2018 

Adverse events should be reported. Reporting forms and 

information can be found at https://yellowcard.mhra.gov.uk. 

Adverse events should also be reported to Tillotts Pharma 

UK Ltd. Tel: 01522 813500. 

References: 1. Greenberg GR et al. N Engl J Med 1994;331:836–841. 2. Rezaie A 

et al. Cochrane Database Syst Rev 2015;6:CD000296. 3. Madisch A et al. Int J 

Colorectal Dis 2005;20(4):312–316. 4. Hofer KN. Ann Pharmacother 2003;37: 

1457–1464. 5. Miehlke S et al. Gastroenterology 2008;135:1510–1516. 6. Gross V 

et al. Aliment Pharmacol Ther 2006;23:303–312. 7. Hartmann F et al. Aliment 

Pharmacol Ther 2010;32(3):368–376. 8. Danielsson A et al. Scand J Gastroenterol 

1992;27(1):9–12. 9. Entocort ® CR 3mg Capsules – Summary of Product 

Characteristics. 10. Entocort ® Enema – Summary of Product Characteristics. 

Date of preparation: 

February 2020. 

PU-00317. 


7

ADVERTORIAL FEATURE 

BOWEL CANCER AWARENESS 

MONTH – DETECT THE UNDETECTED 

WITH ARTIFICIAL INTELLIGENCE 

Medtronic the Global leader in medical technology recently 

launched the GI Genius TM intelligent endoscopy module. GI 

Genius is the first commercially available system in Europe 

that uses artificial intelligence (AI) to detect colorectal polyps. 

It provides endoscopists with a powerful new solution in the 

fight against colorectal cancer. At UEG Week 2019, expert 

gastroenterologists gathered to discuss different aspects of 

the use of AI in endoscopy and individual experiences with GI 

Genius. 

Colorectal Cancer (CRC) is the third most common cancer in the 

world with 1.8 million new cases occurring each year. 1 In Europe the 

incident rate is particularly high with 60.3 new cases per 100,000 

people compared to 19.3 new cases per 100,000 people globally. 1 

April is Bowel Cancer Awareness Month in the UK featuring events 

and fund raisers in support of charities. 

More than 90% of colorectal carcinomas are adenocarcinomas and 

may be detected during a colonoscopy by a skilled gastroenterologist. 

Once detected, the five-year survival rate for localized colon cancer 

is 90%. 2 Regular screening is essential in the prevention of CRC as 

polyps may take 10 to 15 years to develop and are easily removed in 

the early stages. A study by Corley et al. on 300.000 colonoscopies 

performed by 136 doctors shows that the individual adenoma 

detection rate (ADR) varies between 7.4 and 52.5%. 3 

Colonoscopy is affected by a high miss rate 

The adenoma detection rate (ADR) is the gold standard when it comes 

to evaluating the quality of the endoscopist in screening for colorectal 

cancer. The benchmark for ADRs is currently 25% for all patients (30% in 

men and 20% in women). 4 Colonoscopy is still affected by a high miss 

rate of neoplastic lesions and varying ADRs by different endoscopists. 5 

Factors that influenced the results of a colonoscopy were the ADR 

of the individual examiner, the time of day and physician’s fatigue 

level, the colonoscopy device employed, and the patient population. 6 

Afternoon procedures have a 12.4% reduction in mean polyp 

detection compared to morning procedures. Polyp detection rates 

decline throughout the day, potentially due to physician fatigue. 6 

How GI Genius works 

The endoscopy module uses advanced artificial intelligence. When it 

detects anomalies of the intestinal mucosa it highlights the area with 

a visual marker in real-time and acts as a virtual second observer 

during the endoscopic exam. Studies have shown that a second 

observer present during the colonoscopies increases the ADR. 

Improving ADR by 1% results in a decreased risk of CRC by 3%. 3 


Picture 1: GI Genius intelligent endoscopy module 

Picture 2: Visual markers on screen during colonoscopy when the GI 

Genius module detects anomalies of the intestinal mucosa 

8

ADVERTORIAL FEATURE 

The GI Genius module supplements the colonoscopy procedure 

with real-time image analysis powered by deep learning algorithms. 

The module’s algorithm achieved 99.7% sensitivity per lesion and 

had a false-positive rate of less than 1%. The polyp detection 

software noticed polyps 82% of the time faster than the expert 

endoscopist with a mean reaction time of -1.27 seconds. 5 

The GI Genius module consists of two parts: 

1) the module itself is a small box that seamlessly integrates with 

existing colonoscopy equipment 

2) the polyp detection software 

The future of Artificial Intelligence (AI) in 

gastroenterology. 

Mike Wallace, a US based gastroenterologist, said he was excited to 

see AI entering the field of gastroenterology. It could help with the early 

detection of lesions as well as the classification of them. Previously, 

AI learning was based on rules. This turned out not to be successful 

when it comes to image analysis. Recently AI learning has been based 

on image datasets. The software has a large set of validated images 

to learn from and can derive its own rules how to differentiate between 

e.g. different types of colon tissues and anomalies. 7 

Questions to Prof Pradeep Bhandari, 

Queen Alexandra Hospital in 

Portsmouth, UK 

Prof Bhandari has tested GI Genius extensively and was 

one of the experts present at the launch event at UEG week. 

Here we have conducted a short interview with him asking 

him about his experiences and thoughts on the use of AI in 

colonoscopy. 

1. What are the benefits for patients? 

Colonoscopy has a 10-15% adenoma miss rate. ADR & 

PDR can vary depending on the skills and experience 

of the endoscopist. Using GI Genius would standardise 

the detection rates and minimise the variation. This will 

improve the confidence of the patient in the quality of 

the procedure. 

2. What patient groups would particularly benefit from 

GI Genius? 

Patients with multiple polyps and those with really subtle 

and flat polyps as they are commonly missed by average 

endoscopist. 

Integrating advanced technologies such as GI Genius will help with 

diagnostic endoscopy. It will not replace the endoscopist but it will 

help with learning and training. When integrated into daily practice, 

artificial intelligence (AI) may offer a reliable, and ever-vigilant 

“second observer” and a learning community based on sharing 

knowledge and experiences. 8 

References 

1. http://www.crcprevention.eu/index.php?pg=colorectal-cancerepidemiology 

3. What are your thoughts on the current state of early 

detection options for patients with pre-cancerous 

polyps? 

The current state of detection is very much dependent 

on the skills and experience of the endoscopist with 

wide variations resulting in post colonoscopy Interval 

Cancers. 

4. What results have you experienced using GI 

Genius and how would you describe the process 

of integrating GI Genius into your colonoscopies? 

2. https://www.cancer.org/cancer/colon-rectal-cancer/detectiondiagnosis-staging/detection.html 

3. Corley DA et al. NEJM 2014; 370: 1298–1306 

4. Liem B and Gupta N. Transl Gastroenterol Hepatol. 2018; 3: 19 

5. Hassan C et al. Gut 2019; Published Online First: 15 October 

2019 

6. Lee et al. Am J Gastroenterol. 2011;106(8):1457-65. doi: 

10.1038/ajg.2011.87 

7. Presentation: Prof Mike Wallace, Ruffle et al Am J Gastro 2018 

8. Alagappan M, Glissen Brown JR, Mori Y, et al. World J 

Gastrointest Endosc. 2018 Oct 16; 10(10): 239–249. 

Very good experience. Very low false positive, high 

sensitivity and detects very flat and subtle lesions. 

It will be very helpful during training lists and during 

procedures performed by endoscopists performing low 

volume procedures as it will standardise the quality. 

5. How do you see artificial intelligence playing a role 

in the future practice of gastroenterology? 

Huge role from detection to characterisation to decision 

making and choosing the correct treatment option to 

setting surveillance intervals. Importantly, it will change 

the culture from biopsy based decision making to 

endoscopic AI based decision making. 


9

FEATURE 

RISKS OF HEPATIC DECOMPENSATION 

AND MORTALITY IN PATIENTS WITH 

CIRRHOSIS REQUIRING SURGERY 

Dr Melissa Bautista, Bradford Teaching Hospitals, NHS Trust 

Dr Victoria Appleby, Bradford Teaching Hospitals, NHS Trust 

Dr Sulleman Moreea, Bradford Teaching Hospitals, NHS Trust 


Introduction 

Liver disease is the fifth major cause of death in England and Wales (1) ; 

patients with liver disease are presenting at an earlier age with a fivefold 

increase in the development of cirrhosis in 35 to 55 year olds observed 

in the last ten years (2). As a result of the increasing prevalence, 

preoperative assessment and elective surgery is been performed more 

frequently in patients with advanced liver disease and up to 10% of 

patients with end-stage liver disease may have surgery in the last two 

years of their life (3). It is recognised that patients with chronic liver 

disease pose a greater risk of both hepatic decompensation and death 

in both abdominal and non-abdominal surgery when compared to 

healthy individuals due to the effects of surgery and anaesthesia on the 

liver. 

Anaesthetic and surgical considerations in 

the setting of liver cirrhosis 

Drugs 

The liver is a primary site of drug metabolism within the body and 

physiological changes which occur in cirrhosis including reduced 

liver cell mass, porto-systemic shunting of blood and a reduction 

in the concentration of drug binding proteins (albumin) can impact 

on drug availability and lead to an increased risk of hepatotoxicity. 

Haemodynamic abnormalities occurring in patients with cirrhosis 

result in increased cardiac output and decreased systemic vascular 

resistance (4) therefore inhalational anaesthetic agents which 

reduce hepatic blood flow should be avoided due to the risk of 

decreased tissue perfusion as a result of shunting. The impairment 

of drug metabolism is proportional to the degree of synthetic 

disruption within the liver (5). In the context of surgery, anaesthetic 

agents including halothane should be avoided, and the use of 

sedatives or narcotic analgesics which depress the central nervous 

system may precipitate an episode of hepatic encephalopathy. 

Pulmonary dysfunction 

Arteriovenous shunting of oxygen secondary to hepato-pulmonary 

syndrome, hepatic hydrothorax and respiratory compromise with 

diaphragmatic splinting secondary to abdominal ascites are typical 

pulmonary complications resulting in hypoxaemia in patients with 

liver cirrhosis (7). 

Complications of portal hypertension and synthetic 

dysfunction 

Haemorrhage secondary to thrombocytopenia and coagulopathy, 

sepsis, hepatorenal syndrome and liver failure are the most 

common causes of perioperative mortality in patients with liver 

cirrhosis. Increased bilirubin and creatinine levels together with 

a decreased albumin level are associated with a greater rate of 

mortality (8). 

Timing of surgery: Emergency Vs Elective 

Emergency cases should proceed without delay. However, poorer 

outcomes are exhibited in those with decompensated liver disease 

compared to those with normal liver function (9,10). Elective 

procedures are contraindicated in patients with liver disease in the 

following circumstances; 

• Acute Liver failure 

• Acute viral hepatitis 

• Acute Alcoholic hepatitis 

• Acute renal failure 

• Severe coagulopathy (despite correction) 

• Hypoxemia 

• Cardiomyopathy 

• ASA class V : Moribund patient 

Assessing the risk of surgery in liver disease 

Two scoring systems: Model for End stage Liver Disease (MELD) 

and Child Turcotte Pugh score help to stratify the risk of surgery in 

the context of cirrhosis (11). 

MELD 

The MELD score is best calculated by accessing OLTcalc on app 

store for apple and android; 

Links to download app; 

10

FEATURE 

Apple: https://apps.apple.com/gb/app/oltcalc/id1078036171 

Android: https://play.google.com/store/apps/details?id=net.uk.sjg. 

oltcalc&hl=en 

Or calculated as follows: 

The MELD score is calculated by: 

10 * ((0.957 * ln(Creatinine)) + (0.378 * ln(Bilirubin)) + (1.12 * 

ln(INR))) + 6.43 

(creatinine and bilirubin = µmol/L) 

Child Turcotte Pugh (CTP) 

Each measure is scored 1-3, with 3 indicating most severe 

derangement. Chronic liver disease is classified into Child-Pugh 

class A to C, using the cumulative score from the table below. 

cholecystitis leads to an increased rate of misdiagnosis of cholecystitis 

in cirrhotic patients presenting with acute abdominal pain. 

There is an increased risk for post-operative hepatic decompensation 

(7.7% of laparoscopic cholecystectomies and 18.1% of open 

cholecystectomies (14)) and an increased requirement for conversation 

of laparoscopic to open cholecystectomy in patients with cirrhosis. 

Better outcomes are exhibited in laparoscopic surgery compared to 

open surgery. 

MELD 11-13 and Child A & B may undergo cholecystectomies for 

symptomatic gallstones (mortality of 0% -6% (15)). 

Summary for biliary surgery 

• Avoid biliary surgery in MELD >13 and Child C 

• Laparoscopic cholecystectomy is preferred over open 

cholecystectomy 

Measure 1 point 2 points 3 points 

Total bilirubin, 

μmol/l 

Serum albumin, 

g/dl 

50 

>3.5 2.8-3.5 9 points) >70% 

From a large retrospective study, a MELD score of 14 or greater was 

associated with a poor outcome (14). 

Biliary surgery 

Generally, there is an increased susceptibility to gallstone in cirrhotic 

patients and gallbladder thickening due to cirrhosis rather than 

Hernia repairs in emergency cases (incarceration etc.) should 

proceed without delay and should be managed in the following 

way; 

• Optimise the patient’s platelets, coagulation and renal function 

• Review by the hepatology team prior to operation 

• Daily hepatology review postoperatively 

• Long-term ascitic drain to be left in situ and left on open drainage 

• Volume of ascites drained should be assessed daily and 

replaced with albumin as per protocol (100 ml of 20% Human 

Albumin Solution for every 2.5L ascites drained 

• Daily U&Es and correction of renal dysfunction 

• Long term drain to be removed when the 24 hr ascites volume 

FEATURE 

Cardiac surgery 

Retrospective analysis of 44 patients undergoing open heart 

surgery at the Cleveland Clinic over a 10-year period found the 

mortality in each Child Pugh class as below(18): 

• Child A: 3% 

• Child B: 46% 

• Child C: 46% 

A study of cirrhotic patients undergoing cardiopulmonary bypass with 

CTP score 8 had a 90-day mortality rate of 70% (19). 

Trans-jugular intrahepatic portosystemic 

shunt (TIPS) 

TIPS prior to surgery to reduce portal hypertension preoperatively 

has shown to improve surgical outcomes. The study supporting 

this consisted of 25 patients with a MELD score of 15 (28% Child 

C) showed a perioperative morality risk of 12% with prophylactic 

TIPS. Therefore, prophylactic TIPS 4-6 weeks prior to a procedure 

may allow patients to undergo surgery which would otherwise be 

contraindicated (20). 

Summary 

• Patients with well compensated cirrhosis (Child A) are reasonable 

candidates for most types of elective surgery. 

• Emergency surgery will carry a higher risk of hepatic 

decompensation and mortality however in the case of lifethreatening 

situations this is unavoidable. 

References 

1. http://www.britishlivertrust.org.uk/ accessed 17th September 2014 

7. Runyon, BA. Surgical procedures are well tolerated by patients 

with asymptomatic chronic hepatitis. J Ciin Gastroenteroi. 1986; 8: 

542–544 

8. Suman A, Carey W, Assessing the risk of surgery in patients with 

liver disease, Cleveland Clinic Journal of Medicine, April 2006, Vol 

73, Number 4. 

9. Csikesz, N.G., Nguyen, L.N., Tseng, J.F. and Shah, S.A., 2009. 

Nationwide volume and mortality after elective surgery in cirrhotic 

patients. Journal of the American College of Surgeons, 208(1), 

pp.96-103. 

10. Mansour A, Watson W, Shayani V et al. Abdominal operations in 

patients with cirrhosis: still a major surgical challenge, Surgery 

1997: 122: 730-735 

11. Farnsworth, N., Fagan, S.P., Berger, D.H. and Awad, S.S., 2004. 

Child-Turcotte-Pugh versus MELD score as a predictor of outcome 

after elective and emergent surgery in cirrhotic patients. The 

American journal of surgery, 188(5), pp.580-583 

12. Garrison RN, Cryer HM, Howard DA et al. Clarification of risk 

factors for abdominal operations in patients with hepatic cirrhosis. 

Ann Surg 1984; 199: 648-655 

13. Befeler AS, Palmer DE, Hoffman M et al. The safety of intraabdominal 

surgery in patients with cirrhosis: model for end-stage 

liver disease score is superior to Child-Turcotte-Pugh classification 

in predicting outcome. Arch Surg 2005; 140:650–655. 

14. Laurence JM, Tran PD, Richardson AJ, Pleass HC, Lam VW. 

Laparascopic or open cholecystectomy in cirrhosis; A systematic 

review of outcomes and meta-analysis of randomised trials. HPB 

(oxford) 2012;14:153-161 

15. de Goede B, Klitsie PJ, Hagen SM, van Kempen BJ, SPronk S, 

Metselaar HJ, et al. Meta-analysis of laparascopic versus open 

cholecystectomy for patients with liver cirrhosis and symptomatic 

cholecystolithiasis. Br J Surg 2013; 100:209-216 

16. Carbonell, A.M., Wolfe, L.G. and DeMaria, E.J., 2005. Poor 

outcomes in cirrhosis-associated hernia repair: a nationwide 

cohort study of 32,033 patients. Hernia, 9(4), pp.353-357. 


2. http://www.bsg.org.uk/clinical/commissioning-report/ 

management-of-patients-with-chronic-liver-diseases.html 

accessed 17th September 2014 

3. O’Glasser, A.Y., Haranath, S.P. and Enestvedt, B.K., 2015. 

Perioperative management of the patient with liver disease. 

WebMD emedicine 

4. Amarapurkar DN. Prescribing medications in patients with 

decompensated liver cirrhosis. Int J Hepatol 2011;2011:519–26. 

5. Halank M, Strassburg CP, Hoeper MM. Pulmonary complications 

of liver cirrhosis: hepatopulmonary syndrome, portopulmonary 

hypertension and hepatic hydrothorax, Internist (Berl) 2010 Mar: 

51 Suppl 1:255-63. doi: 10.1007/s00108-009-2503-y. 

6. Patel T, Surgery in the Patient with Liver Disease, Mayo Clinic 

Proceedings, Jun 1999 Vol 74, issue 6, pages 593-599. DOI: 

http://dx.doi.org/10.4065/74.6.593 

17. Mosko JD, Nguyen GC. Increased perioperative mortality following 

bariatric surgery among patients with cirrhosis. Clin Gastroenterol 

Hepatol 2011;9:897-901 

18. Suman A, Barnes DS, Zein NN, et al. Predicting outcomes 

after cardiac surgery in patients with cirrhosis: A comparison of 

Child-Pugh and MELD scores. Clin Gastroenterol Hepatol 2004; 

2:719–723. 

19. Macaron, C., Hanouneh, I.A., Suman, A., Lopez, R., Johnston, 

D. and Carey, W.W., 2012. Safety of Cardiac Surgery for Patients 

With Cirrhosis and Child–Pugh Scores Less Than 8. Clinical 

Gastroenterology and Hepatology, 10(5), pp.535-539. 

20. Kim, J.J., Dasika, N.L., Yu, E. and Fontana, R.J., 2009. Cirrhotic 

patients with a transjugular intrahepatic portosystemic shunt 

undergoing major extrahepatic surgery. Journal of clinical 

gastroenterology, 43(6), pp.574-579. 

12

FEATURE 

UEG Week Amsterdam 2020 

October 10-14, 2020, RAI Amsterdam 

Axel Dignass, UEG President, discusses why he is looking 

forward to UEG Week Amsterdam 2020, which promises to 

be one of the year’s leading digestive health meetings. 

With over 13,000 participants from 122 

countries in attendance in 2019, UEG Week is 

one of the world’s largest and most prestigious 

digestive health meetings. This year, UEG 

Week will take place in the wonderful city of 

Amsterdam – the first time the Dutch capital 

will host the congress since 2012. 

This year’s programme, which is carefully 

pieced together by our Scientific Committee, 

will feature a variety of exciting topics within 

the fields of gastroenterology, hepatology, 

endoscopy, digestive surgery and nutrition. 

A range of interactive session types will 

showcase the very best science in our 

field, ensuring the delivery of a first-class, 

multidisciplinary programme inclusive to all 

attendees, no matter their level of experience. 

Highlights will include the exciting ‘Today’s 

Science, Tomorrow’s Medicine’ initiative, with 

this year’s theme on ‘Innovative Technologies 

Driving Future Medicines’, and the UEG Week 

Hotspot, which will feature the meeting’s most 

controversial sessions and hottest debates. 

so delegates can also benefit from attending 

industry sessions throughout the congress 

programme. 

Practical-minded delegates can visit the 

UEG Week Hands-on areas to increase their 

knowledge of diagnostic and therapeutic 

techniques, including surgical training, 

ultrasonography and endoscopy. 

Incorporating a range of educational formats, 

these sessions provide a unique opportunity 

for attendees to watch, learn and perfect their 

technique under the supervision of some of 

the world’s leading specialists. 

Submitting an abstract to UEG Week is a 

unique opportunity to make your scientific 

achievements visible to a large audience 

who share your interest in digestive health. 

There are a number of sessions dedicated 

to presenting original research, from oral 

presentations to e-Posters, and Top Abstract 

Prizes are awarded to the meeting’s five best 

abstracts submissions, with each awardee 

receiving €10,000 for use on future research. 

Early-bird registration fee 

until May 15, 2020 

Reduced fees for 

Allied Healthcare 

Professionals! 

Abstract submission open 

until April 24, 2020 

@myUEG 

@my_ueg 

We’ve expanded the case-based programme 

for 2020, where situations and specific 

problems experienced in daily clinical 

routines will be debated and discussed by 

experts of all fields. We all learn and grow 

from our mistakes, so it’s worth noting the 

popular ‘Mistakes in…’ sessions. Based on 

the successful UEG article series, we’ve added 

two additional sessions for 2020 to ensure the 

series appeals to a wider range of delegates. 

All of the leading companies in the field of 

gastroenterology are present at UEG Week, 

Hard work, dedication and exceptional 

research will, as always, be acknowledged at 

UEG Week with the inaugural presentations of 

a series of awards, including the UEG Lifetime 

Achievement Award, the Journal Best Paper 

Award and the UEG Research Prize. 

We’re expecting an exciting week of scientific 

advances and updates from the world’s 

leading experts in digestive health and I am 

thoroughly looking forward to welcoming 

new and returning delegates to UEG Week 

Amsterdam 2020. 


Find out more: ueg.eu/week 

13

FEATURE 

AN UPDATE ON COLONIC 

DIVERTICULOSIS 

Adam Harris MD FRCP 

Consultant Gastroenterologist 

Colonic diverticulosis is the condition whereby diverticula, saclike 

protrusions or pockets, form from the lining of the colon. 

Terminology 

Diverticular disease is used to describe asymptomatic diverticulosis 

and the spectrum of complications from colonic diverticulosis. This 

may cause confusion and this term is best avoided. 

Diverticulosis is a condition where diverticula are present without 

symptoms. This may be found during colonoscopy or by CT 

scanning. 

Acute diverticulitis is a condition where diverticula become 

inflamed or infected and is defined as acute onset lower abdominal 

pain with increased white cell count or CRP, fever or CT evidence of 

inflammation. Less that

FEATURE 

Who Needs That 

Valuable Clinic Space? 

Management 

In uncomplicated acute diverticulitis (no temperature or signs of 

sepsis or peritonitis) clear liquid diet for 2-3 days followed by a low 

fibre diet and the use of paracetamol and anti-spasmodic agents 

should be considered. 

The value of antibiotics in uncomplicated acute diverticulitis is 

unclear. In randomised, controlled trials antibiotics did not improve 

recovery or improve outcomes (3,4). 

After an episode of suspected or CT-diagnosed acute diverticulitis 

colonoscopy should be undertaken to exclude colon cancer, 

ischaemic colitis or inflammatory bowel disease (1,2,5). 

Urgent surgical advice should be sought for patients with high 

risk presentations (fever, sepsis, peritonitis) and suspected or 

proven complications (abscess; fistula or perforation). Surgical 

management is beyond the scope of this review (5). 

References 

1. Strate LL and Morris AM. Epidemiology, Pathophysiology and 

Treatment of Diverticulitis. Gastroenterology 2019; 156:1282-1298 

BÜHLMANN IBDoc ® Calprotectin 

helps you to better manage clinic 

resources and improve patient care. 

IBD patients can perform 

their own tests at home 

and read them using 

Smartphone technology. 

IBDoc is now compatible 

with 79 supported devices 

(both Apple and Android). 

■ Rapid quantitative 

calprotectin results for 

patient and clinic 

■ Helps prioritise clinic space 

■ Helps monitor mucosal health and predict flares 

■ Connect remotely with patients 

■ Patient involvement and reassurance 

See how IBDoc can help your clinic 

Contact us to discuss an evaluation 

Email: digestivedx@alphalabs.co.uk 

2. https://cks.nice.org.uk/diverticular-disease 

3. Daniels L, Unlu D, de Korte N, et al. Randomised clinical trial of 

observational versus antibiotic treatment for a first episode of 

CT-proven uncomplicated acute sigmoid diverticulitis. Br J Surg 

2017;104: 52-61. 

4. Mora Lopez L, Ruiz Edo N, Serra Pla S, et al. Multi-centre, 

controlled, randomised clinical trial to compare the efficacy and 

safety of ambulatory treatment of mild acute diverticulitis without 

antibiotics with the standard treatment with antibiotics. Int J 

Colorectal Dis 2017; 32:1509-1516. 

5. https://www.acpgbi.org.uk/content/uploads/2017/02/ 

Commissioning-guide-colonic-diverticular-disease-RCS-2014.pdf 

Tel: +44 (0)23 8048 3000 | Web: www.calprotectin.co.uk 


Gastro-Today_IBDoc_Feb_2020.indd 1 05/02/2020 12:44:25 

15

NEWS 

BSG Conference Letter from Senior Secretary 

Dear Colleague, 

It is a great pleasure to invite you, on behalf of the 2020 Planning 

Committee, to join us at the Annual Meeting of the British Society of 

Gastroenterology taking place in Liverpool 15th – 18th June 2020. 

Last year’s conference programme was evaluated as good or excellent 

by 99% of delegates and 89% thought the conference was value 

for money; we aim to build on the successes of Glasgow 2019 and 

previous years. The meeting will begin on Monday 15th June with 

the Gastroenterology Masterclass, with expert speakers focusing 

on “Practical Management of Common GI and Liver Conditions”. 

Alongside the main Masterclass, for the first time, there will be a Primary 

Care Masterclass with talks on managing important GI/Liver conditions 

in primary care. 

The main programme will then run from 16th – 18th June and will 

include over 50 symposia covering basic and clinical science, stateof-the-art 

lectures from international and UK speakers, clinical updates 

and a translational science masterclass. There will be moderated 

poster rounds each day with prizes for the best poster in each category 

each day. There will also be prizes for the best oral presentation for 

every section. We will have joint symposia with International societies 

including EASL, UEGW and the Dutch IBD Society. On the Wednesday, 

live endoscopy sessions will be transmitted from Leeds covering many 

aspects GastroToday_Jan_2019_v4 of diagnostic and therapeutic 26/01/2019 endoscopy. 09:39 Page We will 1 finish on 

Thursday afternoon with a second plenary symposium featuring the 

top abstracts being presented and a “state of the art talk” on Artificial 

Intelligence – make sure you stay until the end! 

Now in it’s fourth year, the hands-on Endoscopy Village will take place 

on Tuesday and Wednesday. This will feature 10 stations allowing 

personal one to one training in different endoscopic techniques. The 

meeting will be complemented by an integrated industry-sponsored 

programme and the Exhibition area where you can learn more about the 

latest innovations in endoscopy and GI therapeutics and diagnostics. 

This year will feature some new sessions including “Meet the experts 

breakfast sessions” on the Wednesday and Thursday mornings, where 

delegates can discuss complex cases with experts. In addition, there 

will be a Career Survival Session on Sunday 14th June, prior to the 

main conference, with talks focussing on topics such as job planning, 

pensions and managing complaints. 

The meeting is an excellent opportunity for you to catch up with 

colleagues and make new friendships across the GI community of 

physicians, surgeons, pathologists, scientists, nurses, dieticians and 

others working in the field. We expect over 2,000 gastrointestinal 

healthcare professionals to join us in the vibrant city of Liverpool, which 

is always a popular venue for the BSG. 

On Monday late afternoon there will be a welcome reception in the 

Exhibition area and on Wednesday evening we will have a ceilidh in 

Liverpool Cathedral, a fantastic venue – make sure you book a ticket. 

We very much look forward to seeing you in Liverpool in June 2020! 

Dr Stuart McPherson, BSG Senior Secretary and Chair of the 

Programme Committee 


16

NEWS 


17

Insource NEWS with 

Passionate about Endoscopy? 

Work with 18 Week Support 

Gastroenterology departments across 

the UK are under significant pressure 

due to the demands of a growing and 

ageing population. With the increasing 

awareness of cancers and national guidance 

recommending diagnostic procedures, it has 

been estimated that approximately 750,000 

additional endoscopy procedures a year will 

be undertaken by 2020. 

Working for 18 Week Support gives you an 

opportunity to work as part of a dynamic 

expert-led team with the time and resources 

to deliver high-quality end-to-end care to 

NHS patients. 

Endoscopy services 

Our specialist Endoscopy insourcing 

services have been developed to support 

NHS trusts with: 

2WW Urgent referrals 

Routine referrals 

Surveillance cases 

Bowel cancer screening services 

Enhanced sedation (Propofol) lists 

Additionally, we can support Direct Access 

and Rapid Access endoscopy referrals by 

working with the local clinical leads to agree 

strong governance for the management of 

these patients. 

FEATURE 

Raising the standard of care 

Our clinical teams are committed to 

working weekends to provide a wide range 

of clinical services. Many of our clinical leads 

are experts in their field. So not only do 

patients benefit from the work our teams do, 

there is also an opportunity for NHS Trust 

teams to improve efficiencies through new 

techniques or approaches. 

How our insourcing 

service works 

18 Week Support 

Clinical team 

Weekend 

NHS Facility NHS Staff NHS 

processes 


18 

Dr Matthew Banks leads our team of 

expert gastroenterologists, nurses and 

decontamination technicians to provide 

weekend general outpatient clinics and 

endoscopy services. 

We have streamlined our services to 

enable us to take ownership of the entire 

patient pathway from first attendance 

through to endoscopy, follow up and 

discharge as appropriate. 

Our team of gastroenterologists manage 

all other aspects of upper and lower GI 

disorders including; 

Dyspepsia 

GORD 

IBS 

Gastric ulcers 

Swallowing difficulties 

We manage all administration that is 

associated with each patient episode, 

approving clinic letters, reviewing results of 

investigations and ensuring all outcomes 

are communicated to the patient and their 

general practitioner. We have also introduced 

virtual follow up and virtual histology clinics 

into the service. 

Criteria & Quality 

We select Endoscopists with an endoscopy 

orientated career path and performance 

measures above the national average. JAG 

audit data is constantly monitored to ensure 

ongoing quality. Furthermore, we have a 

clinical governance department that is crucial 

to maintaining quality and safety but also 

provides support to both Endoscopists and 

the units within which we work. 

We provide tailored solutions to manage 

capacity from straight forward supply of staff 

to a team based managed solution to a full 

patient pathway including pathology review. 

Our commitment to improving the 

NHS experience 

Like the NHS Trusts we work with, patient 

care is at the centre of everything we do. By 

using any spare weekend capacity within a 

Trust, the 18 Week Support insourcing teams 

are able to see a high volume of patients 

in a short space of time, in the familiar 

surrounding of the NHS Trust. 

An ethical company 

We’re an ethical and transparent company 

that’s financially accountable and financially 

responsible. We’re committed to the NHS 

and the delivery of high-quality care, and to 

helping Trusts reduce RTT waiting times. 

Who we’re looking for 

We are interested in meeting with Consultant 

Gastroenterologists, senior nurses and clinical 

nurse specialists throughout the UK. 

Our remuneration package is second to 

none and is per session rather than per case 

which allows our teams to work in a safe and 

calm environment’ 

About you 

Happy patient 

If you have an excellent NHS record and 

want to help clear NHS waiting list 

backlogs, reduce RTT waiting times and 

provide high-quality patient care, get in 

touch by calling on 020 3966 9081 or email 

recruitment@18weeksupport.com 


www.18weeksupport.com 

Matthew Banks 

Clinical Lead for Gastroenterology 


London 3rd Floor, 19-21 Great Tower Street, London EC3R 5AR 

Birmingham Unit 25, Lichfield Business Village, The Friary WS13 6QG 

GASTROENTEROLOGY TODAY - SPRING 2019 

17

NEWS 

People with Crohn’s and 

Colitis still missing out on 

important care from lack of 

Inflammatory Bowel Disease 

(IBD) Nurse Specialists 

• 1/3 increase in IBD Nursing posts since 

2016 thanks to Crohn’s & Colitis UK 

Campaign ‘More IBD Nurses – Better 

Care’. 

• Almost 1/3 of IBD nurses felt the 

campaign had been influential in securing 

their new posts. 

• Yet, just over 1/2 of total IBD Nursing 

posts needed are currently met. 

Data released today by national charity 

Crohn’s & Colitis UK reveals that only 59% of 

IBD Nursing posts in the UK are currently met. 

This means there is a huge shortage of 270 

IBD Nurses, in order to meet the 2.5 WTE IBD 

Nurses per 250,000 people recommended in 

the 2019 IBD Standards. 

As well as providing clinical care for people 

living with Crohn’s or Colitis (the two main 

forms of IBD), an IBD Nurse Specialist is a 

mentor, emotional supporter and an advocate 

for better care and an end to stigma. Without 

them, people with the conditions are missing 

out on this vital care provision. 

Rosie, living with Crohn’s Disease says, “I’ve 

seen the very worst side of Crohn’s Disease 

and I wouldn’t want anyone to suffer that 

alone, without an IBD Nurse. Everyone with 

Crohn’s or Colitis should have an IBD Nurse. 

These angels changed my life.” 

Rebecca, living with Crohn’s says, “Access to 

an IBD nurse would have made the transition 

to living with Crohn’s Disease that much 

smoother. To know that someone was on the 

end of the phone to talk through any worries, 

concerns or symptoms would have been a 

huge relief.” 

In 2016, we launched our More IBD Nurses – 

Better Care campaign to urge NHS managers 

and commissioners to increase the number of 

IBD Nurses across the UK. 

Since the campaign launch, almost one in 

three IBD Nurses (27%) said that the campaign 

had been influential in securing new nursing 

posts in their trusts and supporting with 

business cases. 

The study also found that the number of IBD 

Nurses has increased by over a third (32%) 

since the campaign launch. But with 270 IBD 

Nurse posts short, there is still a long way to go 

to ensure everyone living with these debilitating 

conditions has access to an IBD Nurse. 

IBD Nurses were also asked in more detail 

about their role, with the survey revealing that 

nurses are working at an advanced level, often 

running clinics independently, prescribing 

medication, and ordering investigations. 

But only 14% of IBD Nurses are educated to 

Msc level, the education recommended for 

advanced practice. That’s why, Crohn’s & 

Colitis UK has launched our Nurse Specialist 

programme to annually fund 10 nurses to 

complete MSc’s in advanced nursing practice, 

and 10 MSc qualified nurse specialists to 

complete Royal College of Nursing Advanced 

Practice Credentialing. 

“Everyone with 

Crohn’s or 

Colitis should 

have an IBD 

Nurse. These 

angels changed 

my life.” 

These Crohn’s & Colitis UK Nurse Specialists 

will be in posts up and down the country, 

building a community of nurses representing 

the charity and advocating for better care for 

people with Crohn’s and Colitis. 

Isobel Mason, Nurse Consultant at the Royal 

Free London NHS Trust and at Crohn’s & 

Colitis UK says, “This is a really exciting, 

ground-breaking programme. We are working 

with NHS employers, universities & the Royal 

College of Nursing to guide nurses in their 

careers and to get the qualifications they 

need. In return, we get all the benefit of these 

inspirational nurses, working closely with the 

charity & it’s supporters. Our aim over the 

next 5 years is to create 100 Crohn’s & Colitis 

UK Nurse Specialists who are well trained, 

supported and visible in hospitals.” 

Pearl Avery, Inflammatory Bowel Disease 

Nurse Consultant a Dorset Country Hospital 

says, “I never set out to be an IBD Nurse 

Specialist when I qualified in 2005, I was 

just grateful to care and work in a vocational 

environment; but nor do patients in my care 

set out to become unwell with a chronic 

disease that impacts so profoundly on 

every part of their lives. Since the first week 

in my role 6 1/2 years ago I realised what a 

fundamental difference nursing can make to 

these people and the Crohn’s & Colitis UK 

Nurse specialist programme is building on this, 

creating an opportunity to share success and 

to continue to support innovation and service 

development. I am honoured and excited to be 

part of the programme.” 

Vida Cairnes, Senior IBD Nurse Specialist 

at Royal Devon & Exeter NHS Trust says, “A 

big part of the IBD Nurse role is acting as 

care co-ordinators and supporters. We help 

our patients navigate their journey through 

the healthcare systems, but also for our 

colleagues within the MDT, supporting them to 

provide the best possible care. 

The Crohn’s & Colitis UK Nursing Programme 

is a wonderful initiative that is going to help 

make me a better nurse and be able to give 

better care. This programme brings us 

together with others that share our values and 

motivation; it has certainly increased my sense 

of worth, which makes me feel more resilient 

and better prepared to face future challenges.” 

Other key findings from the survey revealed 

that although 98% of IBD Nurses provide 

essential advice line services, where patients 

can get in touch with their IBD team for help 

and advice, only 10% have had any formal 

training for this. 75% of the nurses surveyed 

rated stress levels associated with their advice 

line as greater than 8 on a scale of 0-10. (0 = 

no stress, 10 = high level of stress). Several 

advice line services have been suspended 

recently due to unmanageable workloads. 

This stress and lack of training needs 

addressing and so Crohn’s & Colitis UK are 

funding and providing advice line training in 

2020, with the aim of training all IBD Nurses 

across the UK. 


19

NEWS 

Young people with IBD five 

times more likely to develop 

serious infections, new study 

reveals 

(Vienna, December 6, 2019) Young patients 

with inflammatory bowel disease (IBD) 

are five times more likely than the general 

population to develop viral infections that 

can lead to hospitalisation or permanent 

organ damage, a new study published in 

the UEG Journal has found. 1 

In the first study of its kind, researchers 

analysed almost 2,700 IBD patients in a Paris 

referral centre to understand the respective 

roles of IBD activity and drugs in promoting 

systemic serious viral infection (SVI). The study 

identified clinically active IBD and thiopurines 

(a class of immunomodulators used to treat 

an estimated 60% of IBD patients 2 ) as the 

main drivers of infection. Despite the highest 

risk of infection being seen in young patients 

between the ages of 18 and 35, a three-fold 

increased incidence of severe viral infections 

was observed in IBD patients of all ages. 

The study also uncovered a concerning 

link between thiopurine use and a number 

of harmful infections. Whilst IBD patients 

receiving no treatment were at a similar risk 

level to the general population, patients treated 

with immunomodulators were found to be six 

times more likely to develop an SVI. The most 

common SVIs developed by IBD patients were 

identified as Epstein-Barr virus (EBV), which is 

associated with a range of diseases such as 

glandular fever and Hodgkin’s Lymphoma, and 

cytomegalovirus (CMV), an infection which can 

pose a risk to unborn babies. 

of SVIs, as they are less likely to have been 

exposed to viruses such as EBV or CMV before. 

They will therefore mount a less effective immune 

response. Their risk is further elevated by the 

inhibiting effect of the immunosuppressive drugs 

they are treated with.” 

The number of individual IBD cases, which 

encompasses both Crohn’s disease and 

ulcerative colitis, has shown a marked 

increase since 1990, rising from 3.6 

million cases globally to over 6.8 million 

in 2017. 4 Commenting on the increasingly 

heavy burden of IBD, Professor Beaugerie 

added, “The relation between IBD drugs 

and SVIs is especially concerning, as 

presently, hospitalisation due to the serious 

complications that accompany the disease 

is the main cost associated with the 

management of IBD. The growing prevalence 

of IBD across the globe will only add further to 

the pressure placed on healthcare structures.” 

New treatment pathways such as nutritional 

therapies in Crohn’s disease and faecal 

microbiota transplantations (FMT), which 

are not evidenced to be associated with an 

increased risk of SVI, could potentially alleviate 

the strain placed on healthcare systems. 

Therapies such as these could transform the 

course of treatment and confer significant 

benefits to patients. 

The study, which has cast new light on the 

strong association between IBD drugs and 

SVI, emphasises the need for further research 

and funding into the area to improve patient 

outcomes. An investigation into promising new 

treatments should become the next course of 

action if the risk of SVI in IBD patients is to be 

brought closer that of the general population. 

References 

1. Beaugerie L et al. Increased incidence of 

systemic serious viral infections in patients 

with inflammatory bowel disease associates 

with active disease and use of thiopurines, 

United European Gastroenterology Journal, 

2019;0(0):1-11. 

2. Warner B, Johnston E, Arenas-Hernandez 

M, et al. A practical guide to thiopurine 

prescribing and monitoring in IBD, Frontline 

Gastroenterology, 2016;0:1-6. 

3. Fox CP et al. Epstein-Barr Virus- Associated 

Hemophagocytic Lymphohistiocytosis in 

Adults Characterized by High Viral Genome 

Load within Circulating Natural Killer Cells, 

Clinical Infectious Diseases, 2010;51(1):66-69. 

4. GBD 2017 Inflammatory Bowel Disease 

Collaborators, The global, regional, and 

national burden of inflammatory bowel 

disease in 195 countries and territories, 1990- 

2017: a systematic analysis for the Global 

Burden of Disease Study 2017, The Lancet 

Gastroenterology & Hepatology, 2017. 


A correlation was also found between 

thiopurine use and EBV-induced 

hemophagocytic lymphohistiocytosis (HLH), 

an aggressive disease associated with 

high mortality rates. 3 With a third of patients 

estimated to be stopping thiopurine use due 

to adverse side effects, these new findings 

underline the need to find novel therapeutic 

approaches to tackle IBD. 2 

Lead researcher Professor Laurent Beaugerie, 

from the Department of Gastroenterology at 

Saint-Antoine Hospital, commented, “Clinicians 

need to be aware of the substantially increased 

risk of SVI in patients with IBD, which had 

previously remained unclear. Young IBD patients 

are the most vulnerable to the development 

20

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21

POSTERS 

Mapping'the'Distribution'of 

Matt&Davie 1 ,&Diana&E.&Yung 2 ,&Sarah&Douglas 2 

The&University&of&Edinb 

Centre&for&Liver&and&Digestive&Disorders,&The& 

Introduction 

• Angioectasias&(AEs)&are&the&main&cause&of& 

small&bowel&bleeding 

• Patients&typically&present&with&ironKdeficiency& 

anaemia&(IDA)&and/or&GI&bleeding 

• Limited&previous&research&into&small&bowel&AE& 

distribution 

Aims 

• To&map&the&distribution&of&small&bowel&AEs& 

identified&on&capsule&endoscopy&(CE) 

• To&assess&the&clinical&outcomes&of&patients&with& 

high&risk&AEs 

Patient4Cohort 

! 154&patients 

• 164&CEs&reviewed 

• 82&Females/72&Males 

• Average&age&of&patients&– 70.4&years 

Indication 

No.+of+patient+ 

referrals 

Iron%Deficiency,Anaemia,(IDA) 115 

Obscure,Gastrointestinal,Bleeding, 26 

(OGIB) 

Both,IDA,&,OGIB 19 

Others 4 


Methods 

• 10Kyear&retrospective&study,&examining&CEs& 

from&a&single&tertiary&centre 

• Number,&location&&&severity&of&AEs&recorded 

• Saurin classification&used&to&grade&AE&severity& 

• SBTT%&used&to&define&an&AEs&position 

• Clinical&outcomes&reviewed&using&clinical& 

records 

Saurin4classification: 

P0 – clinically& 

insignificant&(top&left) 

P1 – uncertain&bleeding& 

risk&(top&right) 

P2 – high&bleeding&risk& 

(bottom&left) 

Active4bleed4(bottom& 

right) 

Results 

1 st Tertile 

(0K33%) 

2 nd Tertile 

(33K66%) 

3 rd Tertile 

(66K100%) 

Total 

P1s 252 49 43 344 

P2s 137 15 4 156 

Active& 46 4 4 54 

Bleeds 

Total 4354(78.52%) 684(12.27%) 514(9.21%) 554 

Angioectasia (AE),Characteristics 

No. 

Total,number,of,all,AEs,(P0,,P1,,P2,&,active,bleeds) 682 

Number,of,capsules,with,just,P0s 12 

Number,of,capsules,with,>1,clinically,significant,AE 152 

Average,number,of,clinically,significant,AEs,per, 3.6 

capsule,(n=152/164) 

Capsules,with,>10,clinically,significant,AEs 11 

22

POSTERS 

'Small'Bowel'Angioectasias. 

,&John&N.&Plevris 1,2 ,&Anastasios&Koulaouzidis 2 

urgh,&Edinburgh,&UK 1 

Royal&Infirmary&of&Edinburgh,&Edinburgh,&UK 2 

Clinical4Outcomes 

K 75&patients&had&>1&P2/active&bleed&&&had&their&clinical&outcomes&reviewed. 

K 35&managed&conservatively. 

K 40&referred&for&endoscopic&intervention&(with&view&of&Argon&Plasma&Coagulation&Therapy). 

Conservative4(n=35): 

• 18&needed&no&further&followKup 

• 14&returned&with&IDA/bleeding 

• 3&died&of&unrelated&causes 

Intervention4(n=40): 

• 3&died&prior&to&procedure&(unrelated&causes) 

• 37&underwent&endoscopic&procedure&(19UGIE,& 

5PE,&13&DBE) 

In&n=9/37&procedures&– no&identifiable&AEs&observed 

Leaving&28&patients&undergoing&APC&therapy: 

• N=8/28&– never&returned 

• N=20/28&returned&with&IDA/bleeding 

Conclusions 

• AEs&are&heavily&populated&within&the&proximal& 

small&bowel 

• 50%&of&AEs&were&identified&within&the&first&10%& 

of&SBTT 

• Patients&with&high&risk&AEs&(>1&P2/active&bleed),& 

had&a&high&recurrence&rate&of&symptoms& 

(IDA/bleeding),&regardless&of&whether&they& 

underwent&conservative&or&interventional& 

management 

References 

Davie&M,&Yung&DE,&Douglas&S,&Plevris&JN,& 

Koulaouzidis&A.&Mapping&the&distribution&of&small& 

bowel&angioectasias.&Scand&J&Gastroenterol.&2019& 

May&5:1K6. 


23

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